| Office visit established patient straightforward CPT 99212 • Office Visits | $38 | $38 | $38 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $75 | $75 | $75 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $151 | $151 | $151 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $204 | $204 | $204 |
| Initial hospital care low complexity CPT 99221 • Office Visits | $147 | $147 | $147 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $200 | $200 | $200 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $294 | $294 | $294 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $59 | $59 | $59 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $107 | $107 | $107 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $153 | $153 | $153 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $105 | $105 | $105 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $153 | $153 | $153 |
| Consultation office low complexity CPT 99243 • Office Visits | $191 | $191 | $191 |
| Consultation office high complexity CPT 99245 • Office Visits | $299 | $299 | $299 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $963 | $963 | $963 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $76 | $76 | $76 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,604 | $1,604 | $1,604 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $463 | $463 | $463 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,620 | $1,620 | $1,620 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $853 | $853 | $853 |
| Iridotomy laser surgery CPT 66761 • Ophthalmology | $612 | $612 | $612 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $1,472 | $1,472 | $1,472 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $1,058 | $1,058 | $1,058 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $235 | $235 | $235 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $2,222 | $2,222 | $2,222 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $924 | $924 | $924 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $1,635 | $1,635 | $1,635 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $822 | $822 | $822 |
| Excision chalazion single CPT 67800 • Ophthalmology | $144 | $144 | $144 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $963 | $963 | $963 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $198 | $198 | $198 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $70 | $70 | $70 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $146 | $146 | $146 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $75 | $75 | $75 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $166 | $166 | $166 |
| Visual field examination CPT 92083 • Ophthalmology | $41 | $41 | $41 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $48 | $48 | $48 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $45 | $45 | $45 |
| Fundus photography CPT 92250 • Ophthalmology | $66 | $66 | $66 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $77 | $77 | $77 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $60 | $60 | $60 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $72 | $72 | $72 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $2,711 | $2,711 | $2,711 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $2,268 | $2,268 | $2,268 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $2,921 | $2,921 | $2,921 |
| Total shoulder replacement CPT 23472 • Orthopedics | $2,159 | $2,159 | $2,159 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $2,603 | $2,603 | $2,603 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $620 | $620 | $620 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $387 | $387 | $387 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $413 | $413 | $413 |